Introduction: We report the case of a patient admitted in the emergency room as a victim of a run over by a train.

Methods: Orotracheal intubation and a left thoracostomy were performed at the scene. At the emergence room, breath sounds were not present at the left side. Subcutaneous enfisema could be noticed and another chest tube was placed at the left side with an immediate debt of 1100 ml of blood. Heart rate was 120 bpm and systolic blood pressure less than 90 mmHg. Severe bleeding was present at the lower limb and a big hematoma could be noticed at the left shoulder region. FAST did not show intraperitoneal fluid. The examination of the left limb showed an open fracture at the thigh and a perfusion deficit thought to be due to a vascular injury.

Results: In this video, the authors discuss options to manage the massive hemothorax, the mangle extremety, the exposure of the subclavian vessels, the options to treat subclavian artery injuries and damage control tactics to these situations. An extreme alternative to control the bleeding from subcutaneous tissue with packing is also shown.

Conclusion: Advances in prehospital rescue and trauma care are responsible for the survival of critical patients. New challenges are frequent and alternative solutions required to deal with these extreme scenarios.